kidney cancer

Kidney Cancer

Definition

Kidney cancer is a disease in which the cells in certain tissues of the kidney start to grow uncontrollably and form tumors. Renal cell carcinoma, which occurs in the cells lining the kidneys (epithelial cells), is the most common type of kidney cancer. Eighty-five percent of all kidney tumors are renal cell carcinomas. Wilms' tumor is a rapidly developing cancer of the kidney most often found in children under four years of age.

Description

The kidneys are a pair of organs shaped like kidney beans that lie on either side of the spine just above the waist. Inside each kidney are tiny tubes (tubules) that filter and clean the blood, taking out the waste products and making urine. The urine that is made by the kidney passes through a tube called the ureter into the bladder. Urine is held in the bladder until it is discharged from the body. Renal cell carcinoma generally develops in the lining of the tubules that filter and clean the blood. Cancer that develops in the central portion of the kidney (where the urine is collected and drained into the ureters) is known as transitional cell cancer of the renal pelvis. Transitional cell cancer is similar to bladder cancer.

Kidney cancer accounts for approximately 2-3% of all cancers. In the United States, kidney cancer is the tenth most common cancer and the incidence has increased by 43% since 1973; the death rate has increased by 16%. According to the American Cancer Society, 35,710 Americans were diagnosed with kidney cancer in 2004, and 12,480 died from the disease. RCC accounts for 90-95% of malignant neoplasms that originate from the kidney.

Causes and symptoms

The causes of kidney cancer are unknown, but men seem to have a greater risk than women of contracting the disease; the male:female ratio in the United States and Canada is 3:2 as of the early 2000s. There is a strong association between cigarette smoking and kidney cancer. Cigarette smokers are twice as likely as non-smokers are to develop kidney cancer. Working around coke ovens has been shown to increase people's risk of developing this cancer. Certain types of painkillers that contain the chemical phenacetin are associated with kidney cancer. The United States government discontinued use of analgesics containing phenacetin about 20 years ago. Obesity may be yet another risk factor for kidney cancer. Some studies show a loose association between kidney cancer and occupational exposure to cadmium, petroleum products, lead, dry-cleaning solvents, trichloroethylene (TCE), and asbestos. Other risk factors for the development of kidney cancer include Hispanic heritage and preexisting von Hippel-Lindau disease.

The most common symptom of kidney cancer is blood in the urine (hematuria). Other symptoms include painful urination, pain in the lower back or on the sides, abdominal pain, a lump or hard mass that can be felt in the kidney area, unexplained weight loss, fever, weakness, fatigue, and high blood pressure.

Other symptoms may occur if the cancer has spread beyond its original location. Spread of kidney cancer most commonly occurs to the lung (55%), liver (33%), bone (33%), adrenal (20%), and opposite kidney (10%). Lymph node spread is also common, occurring in about 25% of patients).

Diagnosis

A diagnostic examination for kidney cancer includes taking a thorough medical history and making a complete physical examination in which the doctor will probe (palpate) the abdomen for lumps. Blood tests will be ordered to check for changes in blood chemistry caused by substances released by the tumor. Laboratory tests may show abnormal levels of iron in the blood. Either a low red blood cell count (anemia) or a high red blood cell count (erythrocytosis) may accompany kidney cancer. Occasionally, patients will have high calcium levels.

If the doctor suspects kidney cancer, an intravenous pyelogram (IVP) may be ordered. An IVP is an x-ray test in which a dye in injected into a vein in the arm. The dye travels through the body, and when it is concentrated in the urine to be discharged, it outlines the kidneys, ureters, and the urinary bladder. On an x-ray image, the dye will reveal any abnormalities of the urinary tract. The IVP may miss small kidney cancers.

Renal ultrasound is a diagnostic test in which sound waves are used to form an image of the kidneys. Ultrasound is a painless and non-invasive procedure that can be used to detect even very small kidney tumors. Imaging tests such as computed tomography scans (CT scans) and magnetic resonance imaging (MRI) can be used to evaluate the kidneys and the surrounding organs. These tests are used to check whether the tumor has spread outside the kidney to other organs in the abdomen. If the patient complains of bone pain, a special x ray called a bone scan may be ordered to rule out spread to the bones. A chest x ray may be taken to rule out spread to the lungs.

A kidney biopsy is used to positively confirm the diagnosis of kidney cancer. During this procedure, a small piece of tissue is removed from the tumor and examined under a microscope. The biopsy will give information about the type of tumor, the cells that are involved, and the aggressiveness of the tumor (tumor stage).

Treatment

Each person's treatment is different and depends on several factors. The location, size, and extent of the tumor have to be considered in addition to the patient's age, general health, and medical history. In addition, much has changed in the treatment and management of kidney cancer since the 1980s, including new surgical techniques, new anticancer drugs, and the development of effective treatments for advanced disease.

The primary treatment for kidney cancer that has not spread to other parts of the body, which is a Stage I, II, or III tumor, is surgical removal of the diseased kidney (nephrectomy). Because most cancers affect only one kidney, the patient can function well with the remaining one. Two types of surgical procedure are used. Radical nephrectomy removes the entire kidney and the surrounding tissue. Sometimes, the lymph nodes surrounding the kidney are also removed. Partial nephrectomy removes only part of the kidney along with the tumor. This procedure is used either when the tumor is very small or when it is not practical to remove the entire kidney. It is not practical to remove a kidney when the patient has only one kidney or when both kidneys have tumors. There is a small (5%) chance of missing some of the cancer. Nephrectomy can also be useful for Stage IV cancers, but alternative surgical procedures such as transarterial angioinfarction may be used.

The rapid development and widespread use of laparoscopic techniques has made it possible for surgeons to remove small tumors while sparing the rest of the kidney. Most tumors removed by laparoscopy are 4 cm (1.6 in) in size or smaller. Laparoscopy also allows the surgeon to remove small tumors with cryoablation (destroying the tumor by freezing it) rather than cutting.

Radiation therapy, which consists of exposing the cancer cells to high-energy gamma rays from an external source, generally destroys cancer cells with minimal damage to the normal tissue. Side effects are nausea, fatigue, and stomach upsets. These symptoms disappear when the treatment is over. In kidney cancer, radiation therapy has been shown to alleviate pain and bleeding, especially when the cancer is inoperable. However, it has not proven to be of much use in destroying the kidney cancer cells. Therefore radiation therapy is not used very often as a treatment for cancer or as a routine adjuvant to nephrectomy. Radiotherapy, however, is used to manage metastatic kidney cancer.

Treatment of kidney cancer with anticancer drugs (chemotherapy) has not produced good results. However, new drugs and new combinations of drugs continue to be tested in clinical trials. One new drug, semaxanib (SU5416), is reported to have good results in treating patients with kidney cancer. As of 2004, however, semaxanib is still undergoing clinical trials in the United States.

Key terms

Biopsy — The surgical removal and microscopic examination of living tissue for diagnostic purposes.

Bone scan — An x-ray study in which patients are given an intravenous injection of a small amount of a radioactive material that travels in the blood. When it reaches the bones, it can be detected by x ray to make a picture of their internal structure.

Intravenous pyelogram (IVP) — A procedure in which a dye is injected into a vein in the arm. The dye travels through the body and concentrates in the urine to be discharged. It outlines the kidneys, ureters, and the urinary bladder. An x-ray image is then made and any abnormalities of the urinary tract are revealed.

Magnetic resonance imaging (MRI) — A medical procedure used for diagnostic purposes in which pictures of areas inside the body can be created using a magnet linked to a computer.

Nephrectomy — A medical procedure in which the kidney is surgically removed.

Renal ultrasound — A painless and non-invasive procedure in which sound waves are bounced off the kidneys. These sound waves produce a pattern of echoes that are then used by the computer to create pictures of areas inside the kidney (sonograms).

Immunologic therapy (or immunotherapy), a form of treatment in which the body's immune system is harnessed to help fight the cancer, is a new mode of therapy that is being tested for kidney cancer. Clinical trials with substances produced by the immune cells (aldesleukin and interferon) have shown some promise in destroying kidney cancer cells. These substances have been approved for use but they can be very toxic and produce severe side effects. The benefits derived from the treatment have to be weighed very carefully against the side effects in each case. Immunotherapy is the most promising systemic therapy for metastatic kidney cancer.

Prognosis

Because kidney cancer is often caught early and sometimes progresses slowly, the chances of a surgical cure are good. Length of survival depends on the size of the original tumor, the aggressiveness of the specific cells making up the tumor, and whether the cancer cells spread from the kidney to surrounding or distant tissues.

Kidney cancer is also one of the few cancers for which there are well-documented cases of spontaneous remission without therapy. Unfortunately, recurrences can occur even as long as ten years after the original diagnosis and treatment, and cancer can also crop up in the other, previously unaffected kidney.

Prevention

The exact cause of kidney cancer is not known, so it is not possible to prevent all cases. However, because a strong association between kidney cancer and tobacco has been shown, avoiding tobacco is the best way to lower one's risk of developing this cancer. Using care when working with cancer-causing agents such as asbestos and cadmium and eating a well-balanced diet may also help prevent kidney cancer.

kidney cancer

a malignant neoplasm of the renal parenchyma or renal pelvis. Factors associated with an increased incidence of disease are exposure to aromatic hydrocarbons or tobacco smoke. A long asymptomatic period may precede the onset of the characteristic symptoms, which include hematuria, flank pain, fever, and a palpable mass. Diagnostic measures include urinalysis, excretory urography, nephrotomography, ultrasonography, renal arteriography, and microscopic and cytological studies of cells from the renal pelvis. Adenocarcinoma of the renal parenchyma accounts for 80% of kidney tumors, occurring twice as frequently in men as in women; transitional cell or squamous cell carcinomas in the renal pelvis account for approximately 15% and are equally frequent in both men and women. Radical nephrectomy with lymph node dissection is usually recommended for tumors of the parenchyma. Nephroureterectomy is usually recommended for operable tumors of the renal pelvis. Radiotherapy may be used before or after surgery and as palliation for inoperable tumors. Chemotherapeutic agents may induce temporary remission. See also renal cell carcinoma, Wilms' tumor.

cancer

Malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of healthy tissues locally or throughout the body. Cancer is the second leading cause of death in the U.S. after cardiovascular disease. In 2006 the American Cancer Society (ACS) reported that 564,830 Americans died of cancer and that twice that number were newly diagnosed with one form or another of the disease. The most common cancers in the U.S. are lung, breast, colon, prostate, and skin. Because most cancers occur in patients who are 65 or older, the incidence of cancer is expected to increase as the population ages. More than 200 kinds of cancer have been identified. Cancers that arise from epithelial tissues are called carcinomas; from mesenchymal tissues, sarcomas; from glial cells, gliomas; from lymphatic cells, lymphomas; from blood-forming cells, leukemias; from pigmented skin cells, melanomas; from plasma cells, myelomas. Synonym: malignancy (2) See: carcinoma; leukemia; lymphoma; oncogene; sarcoma

Cancer cells have several reproductive advantages over normal cells. They can make proteins that stimulate their own growth or new blood vessels to bring them nourishment. They can produce enzymes that prevent their chromosomes from aging. They can invade the lymphatic system and bloodstream and find places to grow in new tissues (metastasis).

Usually, as cancer cells proliferate, they become increasingly abnormal and require more of the body's metabolic output for their growth and development. Damage caused by their invasion of healthy tissues results in organ malfunction, pain, and, often, death. See: table (Estimated New Cancer Cases and Deaths by Sex, U.S. 2008)

Etiology

Ionizing radiation, ultraviolet light, some viruses, and drugs that damage nucleic acids may initiate the genetic lesions that result in cancers. The best-known and most widespread type of carcinogen exposure, however, is consumption of tobacco. The ACS estimates that one third of the cancer deaths that occur annually in the U.S. are related to nutrition and other lifestyle factors. Some cancers are familial, i.e., genetic; others result from occupational exposures to carcinogens. Ironically, chemotherapeutic drugs used to treat some cancers may damage chromosomes and occasionally cause secondary malignancies.

Symptoms

Symptoms of widespread cancer include pain, malnutrition, weakness, fatigue, bone fractures, and strokelike syndromes. Early warning signs of cancer may be remembered by the mnemonic CAUTION: Change in bowel or bladder habit; A sore that does not heal; Unusual bleeding or discharge; Thickening or mass in the breast or other body parts; Indigestion or difficulty in swallowing; Obvious change in a wart or a mole; Nagging cough or hoarseness. People should seek prompt medical attention if they observe any of these signs.

Diagnosis

The location of a suspected lesion often dictates the means to diagnose cancer: men with urinary symptoms may be screened for prostate cancer with a prostate specific antigen (PSA) test; an alpha-fetoprotein (AFP) test may be used to screen for liver cancer. Several other tumor markers (such as the CA 125 test for ovarian cancer) are used only after a diagnosis has already been made by other means. Endoscopy and radiography are typically used to locate and assess the extent of the disease, but definitive diagnosis still rests on the examination of cytological specimens (such as the Papanicolaou [Pap] test) or the pathological review of biopsy specimens. See: illustration; table (Controversies in Cancer Screening in the General Population)

Screening for cancers can identify some malignancies before they have invaded neighboring tissues or become widespread. The most widely used screening tests include the Pap test for cervical cancer, mammography for breast cancer, prostate specific antigen tests for prostate carcinoma, and occult blood tests and colonoscopy for intestinal cancers.

Treatment

Surgery, chemotherapy, immunotherapy, hormone therapy, radiation therapy, and combined-modality therapies often are effective methods for treating patients with cancer. The specific treatment used depends on the type, stage, and location of the cancer and the patient's general health.

The pain associated with cancer is often severe. Cancer patients may suffer depression and anxiety and have nutritional deficits. Guidelines addressing these issues are readily available, e.g., from the U.S. Department of Health and Human Services' Agency for Health Care Policy and Research. Publications may be obtained by calling 1-800-4-CANCER or from websites such as from the ACS (www.cancer.org). See: chemotherapy.

Patient care

There must be close collaboration among the entire health care team and the patient and family must be encouraged to participate in care . The patient's knowledge of the disease is determined, misinformation corrected, and information supplied about the disease, its progression, its treatment, and expected outcome. Such information should be updated regularly. The patient's and family's coping mechanisms are supported, and verbalization of feelings and fears, esp. with changes in body image, pain and suffering, and dying and death, is encouraged. Participation in local support groups is encouraged for both patients and families.

Assistance is provided with personal hygiene and physical care as needed. Physical care is directed at the maintenance of fluid and electrolyte balance and proper nutrition. Nutrition is a special concern because tumors compete with normal tissues for nutrients and grow at their expense and because the disease or treatments can cause anorexia, altered taste sensations, mouth ulcerations, vomiting, diarrhea, and draining fistulas. Nutritional support includes assessing the patient's status and problems, experimenting to find foods that the patient can tolerate, avoiding highly aromatic foods, and offering frequent small meals of high-calorie, high-nutrient soft foods along with fluids to limit fatigue and to encourage overall intake. Intake of noncaffeinated liquids should be encouraged: 2 quarts per day of juices or other caloric beverages in frequent, small amounts rather than water alone. Elimination is maintained by administering stool softeners as necessary if analgesic drugs result in constipation.

Using careful and gentle handling, the health care professional assists with range-of-motion exercises, encourages ambulation and mobility, and turns and repositions the immobile patient frequently to decrease the deleterious multisystemic effects of immobilization. The patient is made comfortable by correct body alignment, noninvasive measures (such as guided imagery and cutaneous stimulation), and medication (preferably administered on a regular schedule to prevent pain, with additional dosing to relieve breakthrough pain). Emotional assistance includes allaying the patient's fears of helplessness and loss of control; providing hope for remission or long-term survival but avoiding giving false hope; and providing the patient with realistic reassurance about pain control, comfort, and rest. Psychological counseling and antidepressant therapies may be helpful.

Hospice care (at home or in a dedicated center), if needed, is discussed with the patient and family. The goal is to provide good quality of life with minimal discomfort, pain, and restrictions rather than to continue specific therapy. Family members are encouraged to assume an active role in caring for the patient. Communication is fostered between patient and family and other health care providers, and the patient is helped to maintain control and to carry out realistic decisions about issues of life and death.

To provide effective emotional support to the patient and family, health care professionals must understand and cope with their own feelings about terminal illness and death and seek assistance with grieving and in developing a personal philosophy about dying and death. They will then be better able to listen sensitively to patients' concerns, to offer genuine understanding and comfort, and to help patients and family work through their grief.

bladder cancer

A malignancy that arises in the cells of the urinary bladder. In Western nations, most of the cases are transitional cell carcinomas. Common causes include cigarette smoking, occupational exposure to carcinogens, or chronic bladder infection. Symptoms of bladder cancer may include painful urination, bloody urination, or frequent or urgent urination. Depending on the extent of invasion or spread of the tumor, it may be treated with endoscopy, surgery, chemotherapy, or immunotherapy.

bone cancer

Any malignancy of bone tissue. Primary bone tumors (such as osteosarcomas) are rare in adults; they are seen more often in children and adolescents. Secondary or metastatic bone tumors are far more common. Tumors arising in other areas of the body that metastasize to the bones most often spread from organs such as prostate or breast.

breast cancer

cervical cancer

A malignant neoplasm of the cervix of the uterus. With an incidence of 15:100,000, it is the third most common cancer of the female reproductive tract and causes 5% of all cancer deaths among women. Although it may occur in younger women, the average age at diagnosis is 54. The disease is insidious, asymptomatic in the early stages, and best treated when recognized at an early stage.

Etiology

Some strains of the human papillomavirus (HPV) are carcinogenic to cervical epithelium. While there are other risk factors (such as tobacco smoking, early age at first intercourse, and having multiple sex partners), HPV is the major factor responsible for the development of this cancer.

Treatment

Management varies from cryotherapy or laser therapy for low-grade squamous intraepithelial lesions, conization for carcinoma in situ, to hysterectomy for preinvasive cervical cancer in women who are not planning to have children. Stage-related management of invasive cervical carcinoma includes radiation and/or hysterectomy.

Prevention

chimney sweeps' cancer

Cancer of the skin of the scrotum due to chronic irritation by coal soot.

colorectal cancer

Abbreviation: CRC

A malignancy of the colon or rectum. It is the second leading cause of cancer deaths in the U.S. At some time during their lives 6% of Americans will be diagnosed with the disease. In 2008 the ACS estimated that 154,000 Americans would be newly diagnosed with colorectal cancer and that it would cause 50,500 deaths.

Etiology

The cancer occurs more often in people with a family history of the disease, those with familial adenomatous polyposis, and in those with inflammatory bowel diseases such as ulcerative colitis. It also occurs more often in people who are obese than in those who are not and in those who consume a high fat, low-fiber diet.

Symptoms

Symptoms may be absent or may include change in the usual pattern of bowel habits, esp. in those over 40; recent onset of constipation, diarrhea, or tenesmus in an older patient; bright red or dark blood in the stool. Laboratory findings may include iron-deficiency anemia or positive fecal occult blood tests.

Diagnosis

Diagnosis may be suggested by findings on digital rectal examination, anoscopy, flexible or rigid sigmoidoscopy, colonoscopy, virtual colonoscopy, or barium enema examination. It is confirmed by biopsy of suspicious lesions. Prevention includes screening of asymptomatic men and women of average risk starting at age 50, annual home fecal occult blood testing (over a three-day period), and colonoscopy every 10 years. During colonoscopy, removal of benign polyps prevents progression to malignant tumors. If polyps are found, colonoscopy should be repeated in 3 to 5 years (depending on the presence of other risk factors). Detection of colorectal cancer at an early stage via colonoscopy offers patients a very high likelihood of cure rate at 5 years. Neither digital rectal examination nor testing of a single stool specimen from the digital exam provides adequate screening. Patients at increased risk for colorectal cancer (those who have had previous colorectal adenomas or resected cancers or a history of ulcerative colitis or of colon cancer in a first-degree relative younger than 60) should undergo screening more frequently and at an earlier age. When colorectal carcinoma is diagnosed, additional tests are conducted to determine the stage of the disease (chest radiographs, CT, MRI, and blood studies, including carcinoembryonic antigen levels, and liver function studies).

Treatment

Surgical resection performed by laparotomy, minimally invasive surgery, microsurgery, or laparoscopy can cure localized colorectal cancer. Whatever procedure is used, the type of surgery depends on the location of the tumor, and the goal of the surgery is removal of the malignant tumor and adjacent tissue and any lymph nodes that may contain cancer cells. Adjuvant therapies may include chemoembolization of blood vessels that feed the primary tumor or metastases; radiation therapy; brachytherapy; chemotherapy; or monoclonal antibody therapy. Carcinoembryonic antigen is helpful in monitoring patients during and following treatment to determine effectiveness and detect recurrence or metasasis.

Patient care

Health care providers should teach patients the importance of colorectal screening and indicate applicable lifestyle modifications (a low-fat diet, maintenance of a normal body mass index). Patients with familial colon cancer syndromes, such as familial adenomatous polyposis, should be counseled about the need for close surveillance by professional gastroenterologists.

Aspirin and other nonsteroidal anti-inflammatory drugs appear to reduce the number of colon polyps, thus decreasing the risk of developing colorectal cancer. Patients interested in such therapy should discuss its potential risks and benefits with their health care providers.

Patients diagnosed with colorectal cancer who undergo surgery need counseling about the operation, the duration of recovery, and, in many cases, the use of a postoperative colostomy . Before surgery, a stomal therapist consults with the surgeon regarding appropriate stoma location, and the abdomen is marked. The therapist answers questions from the patient and family and begins to develop a relationship that will support the patient through postoperative care and teaching. Patient and family are encouraged to access the ACS (800-ACS-2345 or www.cancer.org) for additional information.

epithelial cancer

epithelial cancer of the ovary

esophageal cancer

fallopian tube cancer

A malignancy that begins to grow in the cells that form the inner surfaces of the fallopian tubes, usually an adenocarcinoma. It is the least common form of gynecological cancer.

familial medullary thyroid cancer

Abbreviation: FMTC

A rare, autosomal, dominantly inherited predisposition to medullary carcinoma of the thyroid. The disease is genetically related to the multiple endocrine neoplasia (MEN) syndromes. However, families affected by FMTC rarely develop hyperparathyroid tumors or pheochromocytoma.

gastric cancer

Adenocarcinoma of the stomach. About 50% to 60% of all carcinomas of the stomach occur in the pyloric region. About 20% occur along the lesser curvature; the rest are located in the fundus, particularly along the greater curvature. Although this form of cancer is common throughout the world in people of all races, the incidence of gastric cancer exhibits unexplained geographic, cultural, and gender differences, with the highest incidence in men over 40 and higher mortality in China, Korea, Japan, Taiwan, Iceland, Chile, and Austria.

From 1930 to the 1990s, the incidence of gastric cancer declined from about 38 cases per 100,000 to about 6 cases per 100,000. In 2010, the ACS estimated there would be 21,000 new cases of gastric cancer in the U.S. and 10,570 deaths from this disease. The prognosis for a particular patient depends on the stage of the disease at the time of diagnosis, but overall the 5-year survival rate is about 19%.

Predisposing Causes

Although the cause of gastric cancer is unknown, predisposing factors include a diet rich in pickled or smoked foods, a history of gastric surgery, and a history of infection by Helicobacter pylori. The disease runs in some families; therefore, there may also be a genetic component.

Complications

Malnutrition occurs as a result of impaired eating, the metabolic demands of the growing tumor, or obstruction of the GI tract. Iron deficiency anemia results as the tumor causes ulceration and bleeding. The tumor can interfere with the production of the intrinsic factor needed for vitamin B12 absorption, resulting in pernicious anemia. As the cancer spreads to regional lymph nodes and nearby structures and metastasizes to other structures, related complications occur.

Signs and Symptoms

In the early stages, the patient may occasionally experience pain in the back or in the epigastric or retrosternal areas that is relieved with nonprescription analgesics. As the tumor grows, the patient may notice a vague feeling of fullness, heaviness, and abdominal distention after meals. Depending on the progression of the cancer, the patient may report weight loss due to disturbance of the appetite; nausea; and vomiting. There may be dysphagia and coffee-ground vomitus if the tumor is located in the cardia and slowly bleeds. Weakness and fatigue are common. Because early symptoms include chronic dyspepsia and epigastric discomfort, patients may self-treat with OTC antacids or histamine blockers, delaying prescribed therapies and allowing the cancer to progress.

Palpation of the abdomen may disclose a mass. A skilled examiner may be able to palpate enlarged lymph nodes, esp. in the supraclavicular and axillary regions.

Treatment

Radical surgery to remove the tumor is possible in more than one third of patients. Even in the patient whose disease is not considered surgically curable, resection may temporarily ease symptoms and improve the patient’s response to chemotherapy and radiation therapy. The nature and extent of the lesion determine the type of surgery. Surgical procedures include gastroduodenostomy, gastrojejunostomy, partial gastric resection, and total gastrectomy. If metastasis has occurred, the omentum and spleen may have to be removed.

Chemotherapy for GI tumors may help control signs and symptoms and prolong survival. Gastric adenocarcinomas respond to several agents, including fluorouracil, carmustine, doxorubicin, and mitomycin. Tumors that express HER2 antigens respond to treatment with trastuzumab (a monoclonal antibody that targets the human epidermal growth factor). Antispasmodics, antacids, and proton pump inhibitors may help relieve GI acidity and reflux symptoms. Antiemetics can control nausea, which intensifies as the tumor grows. Analgesics, sedatives, and tranquilizers are used to control pain and anxiety.

Patient care

Nutritional intake is monitored, and the patient is weighed periodically. The health care provider initiates comprehensive clinical and laboratory investigations, including serial studies as indicated, if these have not already been done. The patient is prepared physically and emotionally for surgery, chemotherapy, or radiotherapy. During hospitalization, all general patient care concerns apply.

Throughout the course of the illness, a high-protein, high-calorie diet with vitamin supplementation helps the patient avoid or recover from weight loss, malnutrition, and anemia, and promote wound healing. Frequent small meals are offered.

To stimulate a poor appetite, antidepressant or steroid drugs may be administered. The patient is instructed in use of all drugs and the expected adverse effects of treatment, as well as in management strategies for these effects.

The patient is encouraged to follow a normal routine as much as possible after recovery from surgery and during radiation therapy and chemotherapy. He should stop activities that cause excessive fatigue (at least temporarily) and incorporate rest periods. The patient should avoid crowds and people with known infections. Home-health care is provided as necessary. If curative treatment fails, palliative care and psychological support continues, with questions answered honestly but tactfully. Home or in-patient hospice care referrals are suggested as available.

Synonym: stomach cancer

hard cancer

head and neck cancer

Squamous cell carcinoma usually arising in the pharynx, oral cavity, or larynx. Research has shown links between human papillomavirus infection, tobacco smoking, and excessive alcohol use and head and neck cancers.

interval cancer

A cancer whose presence is diagnosed in the time between scheduled screening tests, e.g., a breast cancer that is not detected by regular periodic mammography, professional examination, and self-breast exams.

kidney cancer

latent cancer

A cancer that grows slowly and has no important health effect on the patient.

lip cancer

A squamous cell carcinoma of the lower lip usually seen in men or smokers.

liver cancer

Malignancy of the liver that results either from spread from a primary source or from primary tumor of the liver itself. The former is the more frequent cause. Male sex, hepatitis B or C, cirrhosis, and other liver diseases are predisposing factors. The liver is the most common site of metastatic spread of tumors that disseminate through the bloodstream. The prognosis for survival is from a few months to 1 yr.

Symptoms

The disease may cause severe pain and tenderness; cachexia (loss of weight); and encephalopathy. Jaundice is common. The liver is enlarged, its surface is nodular, and a central depression or umbilications can often be detected.

LUNG CANCER: Lung cancer seen endoscopically. The tumor is bleeding after being biopsied.

lung cancer

The deadliest form of cancer in the U.S., responsible for about 159,000 deaths a year, according to statistics published by the ACS in 2011. The term includes four cell types: squamous cell (epidermoid) carcinoma, adenocarcinoma, large cell (anaplastic) cancer, and small cell (oat cell) cancer. The vast majority are caused by carcinogens in tobacco smoke, including second-hand smoke. Other risks include exposure to carcinogenic industrial and air pollutants (asbestos, uranium, arsenic, nickel, chromium, iron oxides, coal dust and radioactive dusts), radon gas concentrations, and familial susceptibility. Survival after diagnosis is poor: only one of seven patients lives for 5 years. However, if detected early (before spreading from the lungs), survival rates rise for most people. Radiofrequency ablation (RFA) is a promising therapy for patients with small lung tumors. Synonym: bronchogenic carcinoma See: illustration

Treatment

Treatment includes lung surgery, radiation therapy, and chemotherapy usually in combination.

Patient care

Staging determines the extent of the disease and aids in planning treatment and predicting the prognosis. Lung cancer is relatively difficult to cure but much easier to prevent. Children and adolescents should be discouraged from smoking tobacco products, and current smokers should be assisted in their efforts to quit, e.g., through referrals to local branches of the ACS, smoking-cessation programs, individual counseling, or group therapy.

Screening and Public Health

Chest x-rays do not show small, early cancers, but CT scanning can be used to screen people who have a long history of smoking and who are 50 to 60 years old. In this high-risk group, screening detects the disease in its early stages when it is most likely to be curable. However, since screening is very expensive, and since there are millions of smokers, the public health costs of mass screening are high compared with the cost of encouraging smokers to quit or of teaching teenagers not to start smoking.

oral cavity cancer

Squamous cell carcinoma of the mouth or tongue. Oral cavity cancers are only rarely caused by salivary gland tumors or sarcomas.

ovarian cancer

Any malignant growth in an ovary. About 85% to 90% of ovarian cancers arise from the surface epithelium of the ovary. In the U.S. in 2008, the ACS estimated there would be about 21,600 new patients diagnosed with ovarian cancer and about 15,200 deaths from the disease. Most cases (70%) are diagnosed when the disease is already at an advanced stage because early detection methods are still unsatisfactory. The early symptoms of the disease are often nonspecific and often mimic irritable bowel (constipation, vague abdominal pain, bloating). Initial laboratory studies (routine blood tests and x-rays) are often unremarkable.

Currently, more women die of epithelial ovarian cancer than of all other gynecological cancers combined. A small percentage of patients with ovarian cancer may have a hereditary predisposition, e.g., they have BRCA-1 or BRCA-2 genes. High-risk women include those with multiple first-degree relatives (mother, sister, daughter) or second-degree relatives (aunt, grandmother, cousin) with histories of breast or ovarian cancer. Preventive surgery to remove the ovaries and fallopian tubes is the only way such women can significantly reduce their risk.

Patient care

Ovarian cancer patients may feel threatened or vulnerable. They benefit from pretreatment support and education. Health care professionals address the patient's psychosocial needs while preparing her for treatment and manage the potential adverse reactions and the treatment and changes related to advancing disease.

The first step in care is typically surgical debulking of the tumor. In this phase of care, the surgical oncologist attempts to remove not only the primary tumor, but also as many small tumorlets found within the peritoneum. The patient and family should be taught about the extensive surgical procedure and what to expect after surgery. After surgery, the patient is monitored for infection, circulatory complications, fluid and electrolyte imbalances, and pain. The patient who is to receive chemotherapy should be taught about major adverse reactions to the usual medications employed, taxanes and platinum-based drugs, such as fatigue, nausea and vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, difficulty concentrating (chemobrain), and myelosuppression, as well as about measures to be taken to prevent and manage these problems. Chemotherapy may be given directly into the peritoneum or intravenously. Depression, anger, frustration, and anxiety are common.

After the acute phase of treatment, the patient may undergo premature menopause; loss of fertility; alterations in body image, sexual function, and family relationships; impaired functional capacity; financial difficulties; and loss of spiritual well-being. The patient should be assessed for mood changes, inability to concentrate, fatigue, insomnia, and other symptoms of depression. Her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history should be reviewed for factors that contribute to depression. Participating in a support group, meeting with mental health professionals, and taking an antidepressant or anti-anxiety medication can help alleviate depression and anxiety.

Advancing or relapsing ovarian cancer may cause complications. These may include development of ascites, intestinal obstruction, deep vein thrombosis, malnutrition and cachexia, lymphedema, and pleural effusion. Current five-year survival rates for ovarian cancer are about 30% to 40%. If ovarian cancer recurs after treatment or fails to regress with treatment, palliative and end-of-life care may aid both patients and their families.

cancer of the pancreas

pancreatic cancer

Carcinoma of the pancreas. The American Cancer Society estimated there would be 37,700 new cases of the disease in the U.S. in 2008, with 34,300 deaths caused by the illness that year. Although the causes of pancreatic cancer are unknown, it has been found in more men than women, more blacks than whites, more smokers than nonsmokers, and more patients with a history of chronic pancreatitis and diabetes mellitus than without. When cancer occurs in the head of the pancreas, where it may obstruct the bile ducts and cause jaundice, the disease is most likely to be diagnosed at an early stage, when it may be most responsive to therapy. Surgical excision of the tumor and treatment with chemotherapy or radiotherapy may prolong survival in some patients. Only 4% of victims of pancreatic cancer survive 5 years. Synonym: carcinoma of the pancreas; cancer of the pancreaspancreatic carcinoma

primary cancer

The original cell or tissue type from which a metastatic cancer arises.

prostate cancer

scirrhous cancer

skin cancer

A broad term that includes basal cell carcinomas, squamous cell carcinomas, and melanomas. Together, these skin cancers are the most common cancers in the U.S. They are all associated with excessive exposure to ultraviolet light, e.g., sun exposure. See: basal cell carcinoma; squamous cell carcinoma; melanoma

Patient care

According to the U.S. Preventative Services Task Force (USPSTF), benefits from routine screening for skin cancers with a total body skin examination are unproven, even in high-risk patients.

stomach cancer

terminal cancer

Widespread or advanced cancer, from which recovery is not expected.

testicular cancer, germ-cell

Any of a group of testicular cancers that include choriocarcinomas, embryonal carcinomas, seminomas, spermatocytic seminomas, sex cord tumors, teratomas, and tumors with mixtures of several different malignant cell types.

cancer of unknown primary site

Disseminated cancer in which the original tissue type is uncertain. Such cancers generally have poor prognoses.

Etiology

Patients with such cancers are usually evaluated for tumors that might respond well to therapy, such as a lymphoma, a thyroid cancer, a germ cell tumor, or neoplasms of the breast or prostate.

cancer of uterus

A malignant neoplasm of the uterus, usually of the endometrium, found most often in women over 50. Other uterine cancers include those that arise in the muscular wall of the uterus (sarcomas), cervical cancers, and trophoblastic cancers. Symptoms may include post menopausal bleeding, bleeding between periods, and irregular, long, heavy periods. Pain during urination and during intercourse may be reported. Diagnosis of endometrial cancer is made by endometrial biopsy. The most common treatment is hysterectomy, although radiation and hormone therapy may be used. See: Bethesda System, The; cervical cancer; cervical intraepithelial neoplasia

vulvar cancer

Any malignant neoplasm of the vulva. Of these, 90% are squamous cell carcinomas; the rest are caused by adenocarcinomas, sarcomas, or Paget's disease.

Vulvar cancer accounts for 4% of all gynecological malignancies. More than 50% of cases occur in postmenopausal women between 65 and 70. Generally, vulvar cancers are localized, slow-growing, and marked by late metastasis to the regional lymph nodes. Treatment may include surgery and/or radiation therapy. See: vulvectomy

Monthly self-examination by women is a noninvasive way to screen for changes in the breast. This method detects many benign and cancerous lumps, but its ability to prolong life is still debated.

Mammography

Breast cancer

Mammography is clearly effective screening in women over 50. Most mammograms are obtained by women in their 40s. The incidence of cancer is higher in later life, when mammography use tends to decline.

Digital rectal examination (DRE)

Colorectal cancer, prostate cancer

DRE is easy to perform and inexpensive but its cancer screening value is unproven; and, when it detects cancers, there is no proof that the test results in better patient outcomes. In addition, DRE detects a very small number of cancers, only those within the reach of the examiner.

Fecal occult blood test

Colorectal cancer

In people over 50, testing stool specimens for hidden bleeding detects many cancers; this detection results in earlier treatment and prolongation of life. The accuracy and value of the test relative to sigmoidoscopy and colonoscopy are uncertain.

Chest x-ray, sputum cytology, CT of the chest

Lung cancer

Prospective studies have yielded conflicting results for any method of screening for lung cancer in smokers, and the costs of screening, e.g., with computed tomography of the chest, may be prohibitive. The tests are of no value to nonsmokers.

Prostate specific antigen (PSA)

Prostate cancer

PSA testing detects many previously undetected prostate cancers but may result in increased death and disease due to complications from subsequent surgery. Refinements in its application may improve its usefulness as a screening tool.

Genetic testing

For predisposition to a variety of cancers

The predictive value of genetic testing for cancer is very small. Experts are debating the emotional and ethical consequences of genetic cancer screening tests.

*Note: Cancer screening tests are most likely to be useful when: (1) the cancer is common and deadly; (2) the test reliably distinguishes between healthy and diseased people; (3) early detection of the disease leads to improved treatments; (4) treatments are safe and well-tolerated; (5) the psychological effects of test results are addressed sensitively and carefully; (6) the tests are applied to people who will truly benefit from them.

Kidney Cancer

DRG Category:

656

Mean LOS:

9.5 days

Description:

SURGICAL: Kidney and Ureter Procedures for Neoplasm With Major CC

DRG Category:

687

Mean LOS:

4.7 days

Description:

MEDICAL: Kidney and Urinary Tract Neoplasms With CC

Kidney cancer is rare, accounting for about 3% of all adult cancers. Kidney cancers are classified by cell type. The three most commonly seen in adults are renal cell carcinoma, transitional cell carcinoma, and sarcoma. Renal cell carcinoma arises in the renal tubules and accounts for more than 90% of kidney cancers. The other types of kidney cancer, transitional cell carcinoma and sarcomas, make up the remaining 10%. Most kidney cancers occur in one kidney only (unilateral) and are large and nodular. Renal metastases from other sites are unusual.

Renal cell tumors usually grow as a single mass; however, several tumors can form in one kidney. Because even large tumors may not cause pain, often the tumor is found only after it has become significant in size. Most are found before metastasis occurs. There are five main types of renal cell carcinoma, all diagnosed by microscopic examination: clear cell, pupillary, chromophobe, collecting duct, and unclassified. Renal cell cancer is also graded on a scale of 1 (have a cell nuclei that is very similar to a normal kidney cell nuclei) to 4 (have a cell nuclei that looks very different from a normal kidney cell nuclei). Staging is a far better predictor of prognosis than grading.

In 2013, statistics from the American Cancer Society reported that there were 65,150 Americans diagnosed with kidney cancer. The 5-year survival rate is as high as 90% if the cancer is confined to the kidneys and as low as 9% if metastasis has occurred. Complications from kidney cancer include renal hemorrhage and metastases to the lungs, central nervous system, and gastrointestinal tract. If it is left untreated, kidney cancer causes death.

Causes

Although the exact cause remains unknown, several factors seem to predispose a person to kidney cancer. Smokers increase their risk of developing kidney cancer by 40%. A link also exists between kidney cancer and occupational exposure to cadmium (found in batteries), asbestos, some herbicides, benzene, and organic solvents, particularly trichloroethylene. Family history, obesity, and sedentary lifestyles are also risk factors for developing renal cell cancer.

Genetic considerations

Mutations in several genes can lead to kidney cancer as part of genetic syndromes, including von Hippel-Lindau (VHL). Renal cell carcinoma is a leading cause of mortality in VHL and occurs in about 25% to 40% of affected persons. About 80% of VHL is transmitted in an autosomal dominant pattern; the remaining 20% is due to new mutations. There is a hereditary form of papillary renal cell carcinoma associated with mutations in several genes, and there are also a few documented cases of familial renal cell carcinoma.

Gender, ethnic/racial, and life span considerations

Kidney cancer occurs twice as frequently in men (who are more likely to be smokers and exposed to cancer-causing chemicals in the workplace) than women, commonly after age 40 with a peak incidence between the ages of 50 and 70. Children and infants diagnosed with kidney cancer usually have Wilms’ tumors or a tumor of the renal pelvis and, with prompt treatment, usually have a good prognosis. It is more common in North Americans with European ancestry as compared to people with African or Asian ancestors.

Global health considerations

The global incidence of kidney cancer is approximately 4 per 100,000 males per year and 3 per 100,000 females per year, but it varies by region. Males may have higher rates because of higher rates of tobacco use. People living in developed countries have an incidence approximately eight times higher than those in developing countries.

Assessment

History

Question the patient about the classic triad of symptoms: hematuria, pain, and an abdominal mass. The most common single symptom is painless hematuria, whereas an abdominal mass is usually a late finding. The patient may also report vague signs and symptoms, such as a dull aching pain in the flank area. One-third of all patients diagnosed have these symptoms. One-third of patients have no symptoms at all, and the diagnosis is made during a routine physical examination. The other third of patients are diagnosed after the cancer has produced symptoms related to distant metastases.

Physical examination

It is not unusual for the patient to have a normal physical examination. Occasionally, the patient appears weak, with an unintentional weight loss since the last examination. The patient may have hypertension, edema, or persistent fever unrelated to cold or flu. The placement of the kidneys, deep within the abdomen and protected by layers of fat, makes palpation of renal masses difficult. On occasion, palpation may reveal a smooth, firm abdominal mass.

Psychosocial

The patient may be preparing to retire or be retired when the diagnosis is made. Consider the patient’s and significant others’ ability to cope with a life-threatening illness at this life stage. The diagnosis may be met with anger. The patient diagnosed with late kidney cancer is facing a possibly terminal diagnosis. Assess support systems and consider making appropriate referrals if needed.

Diagnostic highlights

Test

Normal Result

Abnormality With Condition

Explanation

Kidney sonogram (ultrasound)

Bilateral kidneys are properly located and of normal size with smooth outer contours

Usually a unilateral tumor in one kidney

Serves as alternative to renal dye imaging tests for people with allergies; creates oscilloscopic picture from echoes of high-frequency sound waves that pass over the flank area

Abdominal computed tomography (CT) scan; helical or spiral CT

Bilateral kidneys are properly located and of normal size with smooth outer contours

Usually a unilateral tumor in one kidney

Produces pictures of peritoneal and retroperitoneal cavity, based on differing densities and composition of body tissues; helical or spiral CT is a new rapid CT scan that immediately shows the passage of dye through the kidney; even very small tumors are evident

Interventions

Planning and implementation

Collaborative

Depending on the stage, surgical intervention and further staging is the primary treatment for renal cell cancer. In the early stages, some experts are considering molecular approaches such as sunitinib or sorafenib as adjuvant therapy. A radical nephrectomy (removing the whole kidney, the attached adrenal gland, and fatty tissue that surrounds the kidney), sometimes with lymph node removal, offers the patient the best chance for cure. The procedure is the treatment of choice for localized cancer or in patients with tumor extension into the renal vein and vena cava. Surgical intervention is not curative for disseminated disease. Because of the proximity of the kidney to the diaphragm, the surgeon may explore the pleura on the surgical side. The patient could therefore return from surgery with a chest tube placed to remove blood and air from the pleural space. A partial nephrectomy is reserved for those patients with very small renal cell tumors, those who have cancer in both kidneys, or those who only have one kidney.

Nephrectomies involve large blood vessels and place the patient at risk for postoperative hemorrhage. Frequent assessment and serial vital signs to monitor for shock are part of postoperative management. Patients undergoing a nephrectomy experience moderate to severe pain; for this reason, the anesthesiologist may place an epidural catheter during surgery for pain management with morphine sulfate or other appropriate analgesia. Monitor the patient’s urinary output through the Foley catheter for adequate volume and color and consistency of urine; if the patient’s urine output decreases below 40 mL per hour, notify the physician.

Depending on the final stage of the kidney cancer, the surgeon may refer the patient to an oncologist for follow-up care. Kidney cancer is resistant to radiation therapy, which is used in high doses only when metastases have occurred into areas such as the perinephric region and the lymph nodes. Chemotherapy and hormonal therapy do not affect tumor growth. Although several experimental or alternative medications are being tested, they usually have many side effects or are of limited usefulness. Cytokines, proteins that activate the immune system, are currently being investigated as an approach to treat renal cell cancer by boosting the immune system to destroy cancer cells. Also being investigated are “targeted therapies,” which include antiangiogenesis drugs, which kill cancer cells by cutting off their blood supply. New research on treatment of kidney cancer has shown that kidney-sparing treatment may prolong life. Treatment with partial nephrectomy and cryoablative therapies with laparoscopic technique are now being used when the tumor is small and contained.

Pharmacologic highlights

Medication or Drug Class

Dosage

Description

Rationale

Narcotics

Varies with drug and situation; should be taken on a regular basis to be effective

Patient-controlled analgesia; patient is placed on patient-controlled analgesia pump attached to the peripheral intravenous site

Manage pain

Independent

Two of the most important postoperative priorities are to enhance gas exchange and to maintain the patient’s comfort. Institute pulmonary care on a routine basis. Patients with a smoking history may take longer to recover normal lung function after surgery. Encourage the patient to turn, cough, and breathe deeply at least every 2 hours. Show the patient how to use diaphragmatic breathing techniques and how to splint the incision. Teach the patient how to use an incentive spirometer to improve gas exchange. Ask the patient to describe the degree of pain on a scale of 1 to 10. Instruct the patient on nonpharmacologic methods for pain relief. If the patient is receiving analgesia that is insufficient to relieve the pain, notify the physician.

Patients and their significant others are dealing with stressors that cause extreme anxiety and fear. Spend time each day discussing their concerns, being honest about the patient’s chances for recovery. If the patient experiences an unusual degree of spiritual distress, refer to a chaplain or clinical nurse specialist. The diagnosis of kidney cancer is life-threatening, and the patient may need to work through the issues associated with a serious disease.

Evidence-Based Practice and Health Policy

A meta-analysis of nine cohort studies, which included 5,769,987 participants, revealed an increased risk of kidney cancer of 1.42 times among individuals with diabetes compared to those without (95% CI, 1.06 to 1.91).

In this sample, women with diabetes were 1.7 times more likely than women without diabetes to develop kidney cancer (95% CI, 1.47 to 1.97), and cigarette smoking increased the risk by 1.29 times (95% CI, 1.05 to 1.58).

Documentation guidelines

Respiratory response: Patency of airway; adequacy of ventilation (rate, quality, and presence of adventitious breath sounds); maintenance of chest tube system (suction, presence of air leaks, amount and quality of drainage)

Incisional care: Description of dressing; appearance of wound

Degree of pain; response to interventions to lessen pain

Presence of complications related to the surgical procedure

Amount of urinary output, color of urine, and patency of Foley catheter

Discharge and home healthcare guidelines

Be sure the patient understands what medications are to be taken at home, their effects, and dosages. Explain follow-up information, such as when the physician would like to see the patient. Provide a phone number and written discharge information and arrange for a home visit from nurses if appropriate. Refer the patient and family to hospital and community services such as support groups and the American Cancer Society. Reinforce any postoperative restrictions. Explain when normal activity can be resumed. Make sure the patient understands the need to have ongoing monitoring of the disease. Annual chest x-rays and routine IVPs are recommended to check for other tumors. Emphasize lifestyle choices that can aid in recovery: quit smoking; limit alcohol to one to two drinks per day; eat more fruits, vegetables, and whole grains and less animal fat; and exercise once the patient is able.

Patient discussion about kidney cancer

Q. Does anyone have any experience with kidney cancer? Any information would be appreciated.

A. my sister had a Kidney cancer. at the end they had to remove one kidney but it's been 2 years and there's nothing ever since (she goes threw checkups). i can tel you it was a stressful period and i like to investigate a subject. and the best help i gov was from this site:

Choueiri and colleagues decided to further investigate the link between weight and kidney cancer survival by analyzing data from four medical databases, including The Cancer Genome Atlas (TGCA) project and the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).

The report provides comprehensive information on the therapeutics under development for Kidney Cancer (Renal Cell Cancer), complete with analysis by stage of development, drug target, mechanism of action (MoA), route of administration (RoA) and molecule type.

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